®

Zanamivir (Relenza®)- A new

treatment for influenza

Deaths from influenza are recorded every year in the UK and flu epidemics raise concerns for
the safety of the young, the elderly and other vulnerable groups in the community. Not
surprisingly, the launch of zanamavir (Relenza®) by Glaxo Welcome (Middlesex, UK) has
received much attention in the medical media and lay press. Just who should receive this
treatment and under what conditions it should be given remains to be confirmed in practice.

Action and uses of zanamivir Interpretation of results has been made

Zanamivir is a new treatment of influenza (flu)
A/B licensed for use in adults and adolescents
who present with clear symptoms of infection
during the flu season. It is a selective inhibitor of
viral neuraminidase enzyme which is necessary
for the release of newly formed virus from the
surface of infected host cells. Other mechanisms
have been proposed but not established.
Previously, only amantadine (Symmetrel@) has
been available for treatment of influenza A
infection but largely underused due to limited
activity and its association with CNS side-effects.
Zanamivir by inhalation has been assessed in
the treatment of influenza A/B virus infection in
randomized controlled trials involving over 2000
subjects. The primary outcome was length of time
to alleviation of clinically important symptoms,
but further assessment included the use of
symptom scores, the length of time to return to
normal activities, number of episodes of
disturbed sleep, concurrent use of relief
medication, rate of complications and associated
use of antibiotics. Participants were generally
otherwise healthy volunteers (mean age around
35 years) but one trial did include 110 subjects
regarded as high-risk who were aged over 65
years a n d / o r had stable chronic cardiovascular,
respiratory, endocrine, or metabolic disease.
Laboratory confirmation of the diagnosis of
influenza was obtained in from 57% to over 70%
of cases.
difficult by the use of both intranasal and inhaled
zanamivir. No comparison between formulations
has been attempted and only the latter is
available for prescription. The median reduction
in time to alleviation of symptoms (i.e. shortening
of the illness) varied from 1-1.5 days but was
greatest when zanamivir was commenced within
30 hours of the onset of symptoms. This was
extended up to 2.5-3 days in the small sub-group
classed as high-risk but studies in even older
subjects and other high-risk groups with unstable
chronic illnesses are still awaited. So too is an
accurate assessment of the impact of zanamivir
on subsequent antibiotic consumption.
Dosage and administration
Relenza® contains zanamivir supplied in 5 mg
dry powder blisters and delivered by inhalation
via the Diskhaler (originally developed by Alien
& Hanbury for use with Becodisk®). The
treatment course consists of 2 inhalations twice
daily for 5 days, commenced within 48 hours of the
onset of symptoms.
Summary of prescribing issues
Zanamivir is no substitute for immunization
which remains the preferred approach for
high-risk patients. Indeed, zanamivir is not
licensed for the prevention of influenza.

© 1999 H a r c o u r t P u b l i s h e r s Ltd Intensive and Critical Care Nursing(1999) 15, 369-370 369
Intensive and Critical Care Nursing

• Mainly younger and otherwise healthy • The cost of treatment with zanamivir is £24 per
subjects were studied in clinical trials. course.
Although some older patients and others with
mild asthma were included in one trial, those
with more severe chronic illnesses were In conclusion
excluded. Experience in m a n y high-risk
The impact of influenza on the health of the
groups is therefore generally lacking.
population is such that during an epidemic the
• Zanamivir is not (yet) licensed for use in
resources of the Health Service m a y be stretched
children w h o are recognized as an 'at risk'
almost to crisis point. Any new treatment for
group.
influenza is therefore worthy of serious
• It is necessary that patients who are prescribed
consideration. Zanamivir has been designed
zanamivir are able to manage the Diskhaler
specifically (by computer, no less) to block the
system. This m a y prove difficult for some,
spread of virus and so limit the course of the
especially elderly, people.
illness. Any perceived problems with its use in
• Prompt administration is the key to successful
practice are related less to the drug itself than to
treatment with zanamivir. There seems little
the difficulties of accurately diagnosing flu and
point in commencing treatment beyond
delivering treatment promptly, while trying to
48 hours from the onset of s y m p t o m s and
avoid placing increased pressure on the
results from clinical trials suggest only
healthcare system. In particular, clinical trials
minimal benefit w h e n treatment is started
with zanamivir have so far failed to answer the
after 30 hours.
most important question. Does treatment actually
• Confirmation of the diagnosis m a y prove
prevent deaths in very vulnerable patients? For
difficult. Influenza is associated with febrile
most of us, the advice to go to bed, drink liberal
illness, myalgia, headache, sore throat and
amounts of fluid and take simple remedies such
cough ... but so too are other viral respiratory
as paracetamol to control temperature, is very
infections. Treatment initiated on clinical
sound. However, for patients with respiratory
impression alone is likely to result in the
insufficiency, heart disease and other chronic
inappropriate use of zanamivir on occasion.
illnesses, the risks from flu, despite
Results from clinical trials suggest that this
immunization, m a y be very great and
m a y occur in up to half of those treated in
hospitalizations and the need for antibiotics to
practice. The diagnosis of influenza can be
treat the complications of infection carry
m a d e with more confidence where outbreaks
significant cost. There m a y be a case for
are confined to small closed settings,
providing a course of zanamivir to selected
e.g. residential homes.
patients who are at highest risk and who present
• The fact that patients require rapid access to
year after year with serious complications of
their GP and m u s t be seen at short notice is
influenza virus infection such as influenza
likely to increase pressure in the system. This
pneumonia. This would certainly be appropriate
is in contrast to advice in the past that people
if further trials showed treatment to be effective
with flu, w h o are otherwise healthy, should
in high-risk groups. Used in this way, the
remain in bed and resort to simple measures
potential benefits of zanamivir m a y be
rather than place demands on the healthcare
considered to outweigh the cost of treating
services.
presumed infection, even w h e n wrongly self-
• Evidence from clinical trials suggests that
diagnosed, and it would ensure that treatment
zanamivir b y inhalation is generally well
was commenced early and without burden on the
tolerated. It is possible that hypersensitivity
general practitioner or hospital services.
to the drug will be encountered on rare
occasions. A. M. MacConnachie

370 Intensive and Critical Care Nursing (1999) 15, 369-370 © 1999 Harcourt Publishers Ltd